The overall aim of the proposed study is to improve outcomes in critically ill, mechanically ventilated (MV) tube-fed patients. More specifically, the study seeks to determine the extent to which modification of selected risk factors for aspiration can reduce this potentially lethal complication of tube feedings. Frequent aspiration is especially dangerous in that it greatly increases the probability of pneumonia. Modifiable risk factors for aspiration include feeding site, tube position, patient position, and gastric residual volume (GRV). All of the interventions to be tested in the proposed study are potentially easy to perform; however, their collective efficacy in reducing aspiration has not been tested prospectively. The proposed study is consistent with the NTNR's mission to reduce risk for adverse respiratory outcomes in a variety of individuals, including those who are critically ill. A two-group quasi-experimental design will be employed to compare outcomes (frequency of aspiration and incidence of pneumonia) in 294 critically ill MV tube-fed patients who received Usual Care (2002-2004 cohort) to the same outcomes in 214 critically ill MV tube-fed patients who will receive the proposed Aspiration Risk Reduction Protocol (ARRP). A secondary objective is to describe the extent to which the ARRP decreases use of hospital resources. Data collection will take place over a period of 16 months in three of the same intensive care units where the previous study took place. The ARRP is composed of four interventions: (1) placement of feeding tubes by bedside nurses into the small-bowel when gastric motility is significantly slowed, (2) detection and replacement of malpositioned feeding tubes, (3) elevation of the head-of-bed to at least a 30 degree angle, unless contraindicated and (4) detection and management of high gastric residual volumes (GRVs). A Clinical Nurse Specialist (CNS) with advanced skills in critical care nursing and placement of nasoenteral tubes will be available 40 hours per week to educate and coach caregivers in the three ICUs regarding the ARRP. Algorithms for testing feeding tube placement and for managing high GRVs are included in the ARRP. The primary outcome measures are aspiration of gastric contents (as defined by the presence of pepsin in suctioned tracheal secretions) and pneumonia (as defined by a simplified Clinical Pulmonary Infection Score equal to or greater than 6). Prior to initiation of the study, the ARRP strategies will be reviewed by the appropriate hospital committees for use in all patients in the three ICUs where the study will take place. The Chief Nursing Officer and Medical Directors of the involved ICUs are supportive of the ARRP. A t-test for independent groups will be used to compare Usual Care and ARRP on the outcome variables. Delivery, receipt and enactment of the ARRP will be evaluated by quantitative and qualitative methods. [unreadable] [unreadable] [unreadable]